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FOR OFFICE USE: 1 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> •--------------------------- f. a 5 7 <br /> Permit No... 1 <br /> .-!.I� <br /> (Complete in Triplicate) ------�'�---- <br /> Date Issued-....� ..1....-.. <br /> •-•-••. .------.-•-•••.---•--------- ---- This Permit Expires 1 Year From Date Issued <br /> w;", C%-,arc <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install a wore erein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i <br /> JOB ADDR *' <br /> ES5/LOCATIO �� ...- CENSUS TRACT.....----------.--.-- <br /> - ---... - - - • ---------------- ------- - <br /> Owner's Name.. ---Phone--- <br /> Add <br /> hone._. <br /> - - <br /> Address- @-.l- ...... !./ City. _Zip--------- .................. <br /> Contractor's Name.......... License #.. d -__Phone..."r�+G- ._ �/o <br /> Installation will serve: Residence Apartment House E] Commercial r_1 Trailer Court ❑ <br /> Motel ❑ Other. .. .......... <br /> 001 <br /> Number of living units:..... .....Number of bedrooms-.....Garbage Grinder............Lot Size__tP.4.X/7%S.................._.._....... <br /> I <br /> Water Supply: Public System and name------- ........----- ..................... ............. -------------- -- -------.................Private <br /> ' <br /> Character of soil to a depth of 3 feet: Sand p Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> :. <br /> Hardpan <br /> ,X Adobe ❑ Fill Material.. .... ....If yes, type................................ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.[ .� <br /> NEW .INSTALLATION: {No septic tank,or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size..... 1, <br /> [ } !�-. Liquid Depth.::7.................... <br /> Capacity/v?6.Q-------Type P-A.,* .Material. .. --.F-.:No. Compartments.__,.. ----.�---- <br /> Distance to nearest: Well..:.....�1�......... ..... .. .........Foundation. �... ...... -..- Prop. Line.-S. -- .-.-- -.----. <br /> .LEACHING LINE No. of Lines. ......................Length of each line------ �.Q.�Q-.-_Total Length .. ��.�........ <br /> D' Bax.. ...Type Filter Material470 __. "..Depth Filter Material--.-.f'-�....................... .....�--- <br /> A 10 0 <br /> Distance to nearest: Well_•.��i,..............Foundation---� - ine.-..--.-----------Property L -. - -------------....----- <br /> on r <br /> SEEPAGE PIT Depth.0K_–'3.­ Diameter.... _........Number.......13.__------------------ Rack Filled Yes)) No <br /> i <br /> V low <br /> Water Table Depth......A04---------- - ---- ----------------------Rock Size... d.................---------• e <br /> Distance to nearest: Well./0-6 .............Foundation........... Prop, Line.5..0 .- .-. ....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------------'..._.................-_-..------.Date--.---------------..--- -- ) <br /> Septic Tank (Specify Requirements)--------------------- ------ 1 <br /> Disposal Field (Specify Requirements)---... -----•--------= -•--- --+----------------------------- <br /> --- -- --- - • -- <br /> -------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local''Health District. Home owner or licensed agents <br /> i <br /> signature certifies.the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to becomes ct t War an's ompensation laws of California." <br /> Signed------. . �.. Owner <br /> LI&A <br /> -•----•- --------------- ----------- ---- - --------- <br /> By ..Title.......... <br /> ....... ---------------- --. -----------•-- i <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY..: -------------------------DATE ..... '.7- - <br /> DIVISION OF LAND NUMBER.------. -.......1..-------------------- ------•-----------•. ..............DATE...-------_------ - --_--._....--- --- ---- <br /> ADDITIONAL COMMENTS •----- -------- ----------------- -------------------------------------.. to- <br /> --. .. <br /> --- ---------- -- ----------- -------•-----------------••--------------------------------- ------------- - ......... <br /> ------------- <br /> ................... ------ <br /> f <br /> 6___ <br /> Final Inspeclian by: 1. � - ------------------------ ---------------Date------- .. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7176 3M <br />